Primordial follicle pool depletion is the cause of primary ovarian insufficiency (POI) in most women. POI afflicts 1-4% of women, and genetics contributes as much as 70% to POI. Besides infertility, women with POI are at increased risk for osteoporosis and cardiovascular morbidity and mortality. Currently only karyotype and FMR1 pre-mutation testing are offered to women with POI. Fertility preservation is currently feasible fo women at risk for losing ovarian function, yet biomarkers capable of predicting ovarian insufficiency are lacking. We are interested in identifying genetic biomarkers that associate with POI. We have previously used animal models to identify regulators of primordial follicle depletion and associated genetic pathways. Human ovaries of reproductive age are difficult to access and study, and most of our understanding regarding follicular pool depletion and genesis derived from animal models. Others and we identified several novel genes including NOBOX, SOHLH1, SOHLH2, LHX8, FIGLA, FOXO3A, and FOXL2, and utilized transgenic animal models to show their involvement in primordial folliculogenesis. We previously identified plausible mutations in NOBOX and FIGLA genes in a subset of women with POI, which shows the relevance of genes discovered in animal models to human ovarian development and pathology. Using data from available animal models, we determined that there are currently over 400 genes implicated in ovarian insufficiency. This set of genes we call the ovariome. We propose to use whole exome sequencing on familial POI cases and available 1,000 genomes database as a control, to discover candidate pathologic variants. We will use the top 10 genes and top pathologic variants to replicate their association in 475 POI cases and 1,000 natural menopause controls to be recruited here at Magee Women's Hospital. We have also secured to genotype a second replication cohort with 500 POI cases and 1,000 controls. We will apply SNP array technology on 511 POI cases and 1,000 natural menopause controls to determine if certain genomic imbalances associate with POI. We hypothesize that pathologic mutations in the whole exome will be mutated in greater than 10% of women with ovarian insufficiency, and that a substantial number of these mutations will be located in the ovariome set of genes. We also hypothesize that genomic imbalances detected by high-resolution arrays will be superior to conventional karyotype in identifying genomic imbalances in greater than 10% of women who suffer POI. Our proposal will define new genetic biomarkers for risk assessment of ovarian failure, will help predict women who may benefit from fertility preservation techniques, and will stimulate further basic science investigations by discovering novel pathways relevant to human POI. PUBLIC HEALTH RELEVANCE: Ovarian insufficiency adversely affects women's reproductive potential, psychosocial well being, bone mineralization, cardiovascular health and life span. We propose to determine genetic etiology of human ovarian failure through analyzing genomes of affected women and comparing them to appropriate controls. Identification of novel genetic markers for human ovarian insufficiency will help identify women at risk for increased medical morbidity and mortality as well as offer them interventions to preserve their reproductive options.